April 2016

Dr Rajendra Gurung

Supply of Family Planning Equipment and IEC Materials to Five Earthquake Affected Districts

2

Recommended citation: Gurung, R. (2016). Rehabilitation, Recovery and Strengthening and

Expansion of Family Planning Services (with a focus on Long-Acting Reversible Contraception) In

Five Earthquake Affected Districts. Progress Report. Kathmandu: Ministry of Health and Nepal

Health Sector Support Programme.

Disclaimer: This report has been prepared by the Ministry of Health, Government of Nepal with

financial support from USAID and UKaid and technical and financial assistance from the Nepal

Health Sector Support Programme (NHSSP). The views expressed do not necessarily reflect the UK

Government’s or USAID’s official policies.

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CONTENTS

List of Acronyms .......................................................................................................................... 4

1 Introduction ........................................................................................................................ 5 1.1 Purpose of this Report .......................................................................................................... 5 1.2 Background ........................................................................................................................... 5

2 LARCs service availability and support to program districts ................................................... 7 2.1 Availability of Services, Instruments and Equipment ........................................................... 7 2.2 Gap Assessment for Ensuring LARCs Availability in all Birthing Centres .............................. 8 2.3 Supply of Implant and IUCD Sets and Infection Prevention Instruments ............................. 8 2.4 Follow-up Support ................................................................................................................ 9

Annex 1: Instruments ............................................................................................................ 10 Annex 1.1: Instruments in implant insertion/removal sets ....................................................... 10 Annex 1.2: Instrument in IUCD insertion/removal sets ............................................................ 10 Annex 1.3: Store receipts ........................................................................................................... 10

Annex 2: IEC materials ........................................................................................................... 12 Annex 2.1: Pregnancy rule out job aid ....................................................................................... 12 Annex 2.2: Informed choice poster ............................................................................................ 13 Annex 2.3: Medical eligibility criteria (MEC) wheel for contraceptive use (in Nepali)............... 14 Annex 2.4: MEC wheel English ................................................................................................... 14 Annex 2.5: Family planning decision making tool (front cover of tool) ..................................... 14

Annex 3: Photographs of instrument hand over ..................................................................... 15

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LIST OF ACRONYMS

ANM auxiliary nurse midwife

BC birthing centre

CPR contraceptive prevalence rate

DFID Department for International Development (UKaid)

DHO district health office

DMT decision making tool

FHD Family Health Division

FP family planning

HW health worker

IUCD intrauterine contraceptive device

LARC long acting reversible contraceptive

MEC medical eligibility criteria

MoH Ministry of Health

MoHP Ministry of Health and Population

NHSP-2 Second Nepal Health Sector Programme (2010–2015)

NHSSP Nepal Health Sector Support Programme

SBA skilled birth attendant

SWAp sector wide approach

USAID United States Agency for International Development

VP visiting provider

VSC voluntary surgical contraception

VSC+ voluntary surgical contraception (comprehensive FP)

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1 INTRODUCTION

1.1 Purpose of this Report

This report presents details of family planning (FP) equipment (e.g. long-acting reversible

contraception [LARCs] insertion/removal) sets and infection prevention (IP) equipment supplied to

five earthquake affected districts. This happened under the 2016 programme for the rehabilitation,

recovery and strengthening/expansion of FP services with a focus on long-acting reversible

contraception – (LARC) as implemented by NHSSP in coordination with five district health offices

(DHOs).

This report has three sections:

1. Introduction

2. LARCs service availability and support to program districts

3. Annexes

1.2 Background

The Government of Nepal is committed to improving the health status of its citizens and has made

impressive gains despite conflict and other difficulties. Implementation of two successive health

sector-wide approaches (SWAp): NHSP-1 (2004-09), and NHSP-2 (2010-15), brought about

considerable improvements in the health status of the Nepalese people. Building on this, the

Ministry of Health and Population (MoHP) and its external development partners have recently

prepared a third phase of the programme — the Nepal Health Sector Strategy (NHSS, 2015-2020).

The Nepal Family Planning Programme is working to reduce unmet need for contraception and

promote the rights of women to exercise choice when selecting a contraceptive method. The

unmet need for contraceptives is very high in Nepal (27% in 2011 — up from 25% in 2006) and the

overall contraceptive prevalence rate is low (43% in 2011 for modern methods — down from 44%

in 2006). In addition, large disparities exist in rates of contraceptive use by caste/ethnic group and

by geographical areas while levels of unmet need vary substantially by place of residence.

Although there is no ‘ideal method mix’ recognised by the international community, intrauterine

contraceptive device (IUCD) and implant use in Nepal appears to be particularly low, despite their

availability for almost 50 and 40 years respectively. Among currently married women, IUCDs and

implants represented just 0.7% and 0.8% of the contraceptive method mix respectively in 2006,

and 1.3% and 1.2% respectively in 20111. The current use of modern contraception in Nepal’s hill

zone as of 2011 was lower (40.6%) than the national average (43.2%) and the other two zones

(mountain and Terai).

As a result of the major earthquakes of April and May 2015 and the many aftershocks that

followed, the public health system was seriously impaired and the delivery of regular FP service

constrained, resulting in many women struggling to access the FP methods that they need. It was

clear that FP service strengthening was needed to improve access by women in hard-to-

1 Ministry of Health and Population (MOHP) [Nepal], New ERA, and ICF International Inc. (2012).Nepal Demographic and

Health Survey 2011. Kathmandu, Nepal: Ministry of Health and Population, New ERA, and ICF International, Calverton, Maryland.

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reach/affected areas and in the temporary settlements of displaced earthquake victims. Five

priority districts selected on the basis of:

FP support need (low contraceptive prevalence rate (CPR) and fewer health facilities

providing 5 FP methods);

whether other FP support partners were present in the district; and

recommendations from the Family Health Division (FHD).

The selected five districts are Okhaldhunga, Sindhuli, Nuwakot, Lalitpur and Gorkha.

The activities focus on hard-to-reach, and internally displaced people. A multi-pronged approach

has been used combining strategies discussed and agreed with FHD and USAID, including those

piloted by MoH, NHSSP and USAID, with an emphasis on increasing access to family planning and

improving quality of care.

The visiting provider (VP) approach, piloted in Ramechhap in 2014/15, has also been embraced by

FHD. This approach deploys VPs (senior auxiliary nurse-midwife [ANMs] or staff nurses who are

skilled service providers of LARC services and have coaching/mentoring skills and experience), to

birthing centres (BCs) to support skilled birth attendants (SBAs) deliver LARC or provide direct LARC

services where skilled staff are not available. The delivery of comprehensive FP services through

comprehensive mobile FP camps (VSC+ — voluntary surgical contraception plus) approach, as

piloted in Baitadi and Darchula in 2014/15, was also incorporated in this programme.

Overall, the following recommended activities were identified and supported by this programme:

LARC expansion through mentoring and coaching.

Service delivery through visiting providers in remote areas.

Scale-up and increasing intensity of comprehensive mobile camps.

Demand generation through female community health volunteers (FCHVs) and the media.

Distribution of condom boxes at appropriate places

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2 LARCS SERVICE AVAILABILITY AND SUPPORT TO PROGRAM DISTRICTS

A brief consultative meeting with the DHO team and a one day planning meeting with all health

facility in-charges and the DHO team was carried out in all five districts to determine gaps and

needs for the expansion of FP service with a focus on LARCs services.

2.1 Availability of Services, Instruments and Equipment

Table 1 shows the availability of FP services, the number of birthing centres (BC) and the number of

trained human resources and other information on FP services in the five programme districts. Of

the 294 health facilities in the five districts, 143 had birthing centres. As shown in Table 1, of the

143 BCs, just over two-thirds (69%, n=98) had SBAs, of those only one-fifth (20%, n= 28) BCs were

providing IUCD services. Similarly, although 66 BCs had at least one implant trained provider, only

one-third (33%, n=47) were providing implant services. A lack of necessary supplies (insertion and

removal sets, commodities and minor procedure rooms, etc.) could be a major factor contributing

to the for lack or discontinuation of services in these health facilities. Of the 143 BCs, only 39 BCs

(27%) had IUCD sets available (the lowest was Gorkha at only 18%), while 45 (31%) BCs had implant

sets available. Altogether 122 (85%) of 143 BCs had at least one functional autoclave.

Table 1: Family planning service status in programme districts

Dis

tric

t

# to

tal H

Fs

# o

f B

C

# o

f B

Cs

wit

h S

BA

s

# o

f B

Cs

wit

h im

pla

nt

trai

ne

d H

W

# o

f B

Cs

wit

h

serv

ice

s

# o

f B

Cs

wit

h

IUC

D s

ets

# o

f B

Cs

wit

h

imp

lan

t se

ts

# o

f B

Cs

wit

h

fun

ctio

na

l

auto

cla

ves

# H

Fs w

ith

con

do

m b

ox

# H

Fs w

ith

FP

po

ste

r

# o

f H

Fs w

ith

fun

ctio

na

l to

ilet

for

clie

nts

/pat

ien

ts

IUCDs Implants

Lalitpur 40 18 16 11 2 5 5 5 17 13 15 28

Nuwakot 63 28 17 13 9 9 10 10 20 14 48 39

Okhaldhunga 56 37 31 17 6 17 8 13 32 24 25 53

Sindhuli 56 20 8 10 5 5 9 5 15 23 49 52

Gorkha 79 40 26 15 6 11 7 12 38 46 55 66

Total 294 143 98 66 28 47 39 45 122 120 192 238

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2.2 Gap Assessment for Ensuring LARCs Availability in all Birthing Centres

The initial gap assessment in showed that 100 BCs in

the five districts needed supporting with IUCD sets

and 103 BCs needed implant sets in order to initiate

LARC services. Furthermore, a total of 21 BCs

needed to be provided with autoclaves for sterilizing

FP instruments. Competency-based implant training

to service providers (total need, n=77), and IUCD

coaching (n=70) also created additional need for

implant and IUCD insertion/removal sets. As shown

in Table 2 the maximum need for insertion removal

sets was in Gorkha district (IUCD sets needed in 31

BCs and implant sets in 32 BCs), followed by

Okhaldhunga and Nuwakot. Similarly, there was a

high need for sterilization autoclaves in the BCs of Nuwakot followed by Okhaldhunga and Sindhuli

districts.

Table 2: Need for coaching/mentoring, training, instrument and FP posters support

Dis

tric

t

# to

tal H

Fs

# o

f B

C

# o

f B

Cs

wit

h

SBA

s

# o

f B

Cs

wit

h

imp

lan

t tr

ain

ed

HW

# o

f B

Cs

ne

ed

ing

IUC

D

coac

hin

g

# o

f B

Cs

ne

ed

ing

imp

lan

t tr

ain

ing

# o

f B

Cs

ne

ed

ing

IUC

D s

ets

# o

f B

Cs

ne

ed

ing

imp

lan

t se

ts

# o

f B

Cs

ne

ed

ing

fun

ctio

nal

auto

clav

es

# H

Fs n

ee

din

g

con

do

m b

ox

# H

Fs n

ee

din

g FP

po

ste

r

Lalitpur 40 18 16 11 14 7 11 10 1 27 25

Nuwakot 63 28 17 13 8 15 18 20 8 49 15

Okhaldhunga 56 37 31 17 25 20 29 29 5 32 31

Sindhuli 56 20 8 10 3 10 11 12 5 33 7

Gorkha 79 40 26 15 20 25 31 32 2 33 24

Total 294 143 98 66 70 77 100 103 21 174 102

2.3 Supply of Implant and IUCD Sets and Infection Prevention Instruments

Instruments and equipment along with some IEC materials were handed over to the stores of all

five DHOs in March 2016. Altogether 200 IUCD insertion/removal sets and 309 implant

insertion/removal sets were supplied to enable the resumption or to strengthen implant and IUCD

services. The IUCD sets were supplied to 100 BCs and implant sets to 103 BCs across the five

districts by the respective DHO teams.

Furthermore, a total of 21 autoclaves (2 drum electric autoclaves with surgical drums) for 21 BCs

were supplied to the five districts in March 2016. An informed family planning choice poster for

(n=294) was also supplied to all the districts. Store receipt from all districts acknowledging arrival of

instruments/equipment has been received (see Annex 1.3). Based on the findings of the gap

assessment, each birthing centre with trained service providers but lacking insertion/removal sets,

Health facility in-charges in Nuwakot discussing need for LARCs expansion

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received 2 IUCD insertion/removal sets and 3 implant insertion/removal sets from the district

stores. In addition, each health facility received a decision making tool (DMT), a medical eligibility

criteria (MEC) wheel, and a pregnancy rule out job aid in April 2016 (See Annex 2).

Table 3 shows instruments and IEC materials supplied in the project period to the five districts.

Table 3: Instruments, equipment and IEC materials supplied to the five districts

District Number of BCs Number of IUCD sets supplied

Number of

implant sets

supplied

Number of autoclaves

supplied

Number of informed choice FP posters

supplied

Lalitpur 18 22 30 1 40

Nuwakot 28 36 60 8 63

Okhaldhunga 37 58 87 5 56

Sindhuli 20 22 36 5 56

Gorkha 40 62 96 2 79

Total 143 200 309 21 294

2.4 Follow-up Support

Once the LARCs insertion/removal sets and IEC materials/job aids were provided to the HFs, VPs

carried out quality of care assessment by administering FP quality improvement tools and

identifying activities that may need support for the proper use of equipment/instruments and

information and education communications (IEC) materials. Although, the gap assessment was

carried out at the time of programme planning, it is anticipated that emerging needs will evolve

during programme implementation. The emerging needs will be addressed in agreement with the

respective DHOs and NHSSP.

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Annex 1: Instruments

Annex 1.1: Instruments in implant insertion/removal set

Item Details Unit Qty

1 Implant insertion/removal sets Set 1

2 Sponge holding forceps, Straight 8” Pcs 1

3 Ring forceps Pcs 1

4 Artery forceps, Curved 6" Pcs 2

5 Dissecting forceps, non-toothed Pcs 1

6 Galli pot/stainless steel bowl Pcs 2

7 Implant trocar with cannula Pcs 1

8 Blade holder Pcs 1

Annex 1.2: Instrument in IUCD insertion/removal sets

Item Details Unit Qty

1 Sponge holding forceps, STR 9.5" Pcs 1

2 Vollesellum forceps Pcs 1

3 Vaginal Cusco speculum Pcs 1

4 Uterine sound Pcs 1

5 Mayo scissor, curved 20 cm Pcs 1

6 Kidney tray, 8" Pcs 1

7 Galli pot/stainless steel bowl Pcs 1

8 Straight long artery forceps Pcs 1

Annex 1.3: Store receipts

Nuwakot

11

Okhaldhunga

Sindhuli

Gorkha

12

Annex 2: Information and Education Communication materials

Annex 2.1: Pregnancy rule out job aid

13

Annex 2.2: Informed choice poster

14

Annex 2.3: Medical eligibility criteria (MEC) wheel for contraceptive use (in Nepali)

Annex 2.4: Medical Eligibility Criteria (MEC) Wheel English

Annex 2.5: Family planning decision making tool (front cover of tool)

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Annex 3: Photographs of instrument hand over

Gorkha DHO store

Okhaldhunga DHO store